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1 Disclosures Streptococcal Pharyngitis: Update and Current Guidelines Richard A. Jacobs, MD, PhD Emeritus Professor of Medicine Division of Infectious Diseases I have no disclosures CID 2012:55;e year old previously healthy male Day 1 Onset of sore throat with fever Day 2 Evaluated in office exudative pharyngitis with tender anterior cervical adenopathy, h/o fever and no cough (4/4 of Centor Criteria) Azithromycin started (within 24 hours of onset of symptoms) 1

2 Diagnosis of Gp A Streptococcal Pharyngitis Modified Centor Criteria IDSA (Infectious Disease Society of America) Rapid strep test in adults ACP (American College of Physicians) and the AAFP (American Academy of Family Practice) Modified Centor Criteria Score >4 > Rx empirically 20 year old previously healthy male Day 1 Onset of sore throat with fever Day 2 Evaluated in office exudative pharyngitis with tender anterior cervical adenopathy, h/o fever and no cough (4/4 of Centor Criteria) Azithromycin started (within 24 hours of onset of symptoms) Day 3 PC not better still with sore throat and fever Plan continue azithromycin Day 5 Phone Call not better Diffuse myalgias, difficulty swallowing, pain on (R) side of neck Plan--to finish Azithromycin; encourage fluids; ibuprofen for symptom relief; call if not better 2

3 Day 6 PC--SOB and pleuritic chest pain Instructed to go to ED for evaluation ED evaluation BP 92/54 WBC 21,400 with 51% PMNs and 42% bands Plts 16,000 BUN 80, Cr 4.2 PTT 50; FDP elevated ph 7.29 with elevated lactic acid CXR, chest CT and BCs obtained --CXR Chest CT 3

4 Blood Culture What Went Wrong? Fusobacterium necrophorum Natural History of GpA Streptococcal Pharyngitis w/o therapy, symptoms better in 2-4 days With early therapy (24 hours) symptoms resolve hours sooner Viral Pharyngitis Similar time line 2009;151: ;151; ;151: Fusobacterium necrophorum Anaerobic gram-negative rod An important upper respiratory pathogen in ADOLESCENTS AND YOUNG ADULTS (ages 15-25) Can isolate F. necrophorum from 10% with sore throat Peritonsillar abscesses F. necrophorum isolated in 23% (most in pure culture) c/w gp A streptococcus 17% Fusobacterium necrophorum Complication LEMIERRE S SYNDROME Septic phlebitis IJ vein, bacteremia, septic pulmonary emboli/abscess Estimated to occur in 1 of 400 cases of F. necrophorum pharyngitis (more common than Rheumatic Fever following gp A streptococcal pharyngitis) 4

5 Pharyngitis in Adolescents Take Home Points Fusobacterium necrophorum Resistant to macrolides/azalides (azithromycin/clarithromycin) Sensitive to penicillins, cephalosporins and clindamycin Pharyngitis in the adolescent and young adults (ages 15-25) can be more complicated than previously thought Encourage Rapid Strep Testing Antibiotic stewardship Treat only if positive Take Home Points If you use the Centor Criteria: AVOID MACROLIDES/AZALIDES for empirical therapy in pharyngitis in adolescents and young adults F. necrophorum is resistant to macrolides AND there is increasing resistance of Gp A strep to macrolides Penicillin, cephalosporins, clindamycin, Augmentin are reasonable choices Remember the natural history: If the patient fails to improve think about complications like Lemierre s 5

6 GAS As Cause of Pharyngitis With rare exceptions, antibiotics have no proven benefit as treatment for acute pharyngitis due to organisms other than GAS. This includes Gp C and G strep Predominantly a disease of children 5-15 years of age 20% - 30% Diagnosis by RADT (sensitivity 70% - 90%) If negative > culture (sensitivity 90 95%) GAS As Cause of Pharyngitis Predominantly a disease of children 5-15 years of age 20% - 30% Diagnosis by RADT (sensitivity 70% - 90%) If negative > culture (sensitivity 90 95%) In adults accounts for 5% - 15% Diagnosis by RADT No backup test needed in most cases GAS in Children < 3 Years Old Presentation atypical fever, purulent rhinitis, excoriated nares, diffuse adenopathy Exudative pharyngitis uncommon Rheumatic fever uncommon Requires multiple antigenic exposures Diagnostic testing only in high risk settings Household disease Day care setting 6

7 Therapy of GAS Comments on Therapy Penicillin DOC safety and efficacy, narrow spectrum and cost Amoxicillin often used in children primarily because of the taste of the suspension Some cephalosporins [cefdinir (Omnicef) and cefpodoxime (Vantin)] have been approved for 5 days of therapy would discourage because of broad spectrum Clindamycin resistance 1% > good for patients with IgE mediated reactions to penicillin Azithromycin resistance in the US 5% - 10% Post-Treatment Cultures Even with effective therapy and resolution of symptoms, 7% - 37% of children have positive post-treatment cultures Because it is common and rarely is clinically significant POST TREATMENT CULTURES NOT INDICATED Recurrent Pharyngitis Noncompliance with initial therapy Antibiotic resistance New infection Viral infection in patient who is a chronic carrier Up to 20 % of children can be carriers Unlikely to spread the organism Low risk of Rheumatic fever or suppurative complications Difficult to eradicate carrier state No need to treat asymptomatic carriers 7

8 Household Contacts of GAS In studies examining the role of antibiotic prophylaxis of household contacts of patients with GAS, penicillin prophylaxis has not been shown to reduce the incidence of secondary cases Appendix Pediatr Infect Dis J 2007; 26: When to Treat Asymptomatic Carriers Community outbreaks of rheumatic fever, post-streptococcal glomerulonephritis or invasive Gp A infections Outbreak of Gp A strep in a closed community In the presence of a family or personal history of rheumatic fever If suspect ping-pong spread in a household with multiple recurrent episodes of infection 8

9 Tonsillectomy for GAS Tonsillectomy may be considered in the rare patient whose symptomatic episodes do not diminish in frequency over time and for whom no alternative explanation for recurrent GAS pharyngitis is evident. However, tonsillectomy has been demonstrated to be beneficial only for a relatively small group of these patients, and any benefit can be expected to be relatively short-lived 9